Home ACE Initial Assessment Questionnaire ACE Initial Assessment Questionnaire First Name Middle Name Last Name Date of Birth Marital StatusSingleMarriedSeparatedDivorcedWidowed Ethnic OriginAfricanAsianCaucasianHispanicOther Occupation Postal Address Postal Code Mobile 1 Mobile 2 Email ID Number Place of Work Cycle (days of flow & cycle length) Menarche (age at first mense) Cycle RegularityRegularIrregular Pain During Menses Intermenstrual Bleeding Flow TypeHeavyModerateLight Last Menstrual Period Previous Menstrual Period Currently Sexually ActiveYesNo Dyspareunia (Pain During Sex)YesNo Post-Coital BleedingYesNo Previous STIs/STDsYesNo History of Sexual AbuseYesNo Other Sexual Disorders Surgical History Contraception Details Do you use Tobacco? Do you use Alcohol? PAP Mammogram Ultrasound Blood Workup Current Medications Weight Height Pulse BP Exam Time Upload Additional Documents Accepted formats: PDF, DOC, JPG, PNG I consent to the use of my medical data for anonymous research and reporting. Submit
